简介
在里面国人成都开始的新型冠状HIV（2019-nCoV）发生促使蔓延，现已在多个国家胃癌。我们调查报告结果了在宾夕法尼亚一州认定的月所2019-nCoV染病病症，并所述了该病症的鉴定，病因，医学每一次和经营管理，包含症状在复发第9天请注意现为结核病时的本来轻度疼痛。
该个案特别强调了医学心理医生与区域内，一州和联邦各级公共医疗卫生当局之间的关系协作的来得为重要，以及并不需要并能散播与这种新发染病症状的护理人员有关的医学信息的需求。
2019年12年初31日，里面国人调查报告结果了与湖北省湖北省海南海鱼批发市场有关的人群里面的结核病病症。
2020年1年初7日，里面国人医疗卫生当局认定该簇与新型冠状HIV2019-nCoV有关。尽管本来华盛顿邮报的病症与湖北省海鱼市场的暴露有关，但局限性的临床数据库证明，刚刚发生2019-nCoV社交散播。
截至2020年1年初30日，在多于21个国家/邻近地区调查报告结果了9976例病症，包含2020年1年初20日华盛顿邮报的宾夕法尼亚一州月所胃癌的2019-nCoV染病病症。
全球数限于刚刚同步进行调查报告，以来得好地认识到散播动态和医学癌症区域。本调查报告结果所述了在宾夕法尼亚一州认定的月所2019-nCoV染病的临床和医学形态。
个案调查报告结果
2020年1年初19日，一名35岁的女童经常成现在华盛顿一州罗宾逊霍米塔奇拉州的一家急诊妇产科，有4天的肿胀和客观性发作日本史。病童到妇产科检验时，在候诊室戴上沟罩。回头约20分钟后，他被带到检验室放弃了相关联的指标。
他透露，他在里面国人成都养病家人后于1年初15日返回华盛顿一州。该症状请注意示，他已从宾夕法尼亚一州癌症压制与传染病该里面心（CDC）收到有关里面国人新型冠状HIV愈演愈烈的健康警报，由于他的疼痛和不太也许的之旅，他要求去看心理医生。
上图1-2020年1年初19日（癌症第4天）的后后背和末端胸片
除了高三酸酯血症的病日本史以外，该症状还是其他健康的不吸烟者。体格检验发掘成症状吞咽环境湿气时，心率为37.2°C，血压为134/87 mm Hg，脉搏为每分钟110次，吞咽高频率为每分钟16次，碳含水为96％。肺部听诊揭示有弥漫性，并同步进行了胸片检验，据华盛顿邮报并未发掘成异常（上图1）。
甲型和乙型霍乱的并能小分子缩减测试者（NAAT）为比如问道。获了楔咽拭子头颅骨，并通过NAAT将其送给去仪器HIV性吞咽道病菌。
据华盛顿邮报在48同一时间内对所有测试者的病菌原则上排列成比如问道，包含甲型和乙型霍乱，副霍乱，吞咽道合胞HIV，楔HIV，腺HIV和已知但会导致人类癌症的四种少用冠状HIV株（HKU1，NL63、229E和OC43） ）。根据症状的之旅历日本史，第一时间通知区域内和一州政务院门。华盛顿政务院与紧急护理人员医学心理医生独自一人通知了CDC紧急行动该里面心。
尽管该症状调查报告结果问道他并并未去过海南海鱼市场，也并并未调查报告结果在去里面国人之旅期间与卧床者有任何带入，但癌症传染病压制该里面心的保安医务人员同意有必要根据局限性的癌症传染病压制该里面心对症状同步进行2019-nCoV测试者。
根据CDC最新得来了8个头颅骨，包含抗体，楔咽和沟咽拭子头颅骨。头颅骨热带植物后，症状被送给往家庭分开，并由当地政务院门同步进行全力监测。
2020年1年初20日，癌症传染病压制该里面心（CDC）认定症状的楔咽和沟咽拭子通过系统对逆转录酶-PCR链反应（rRT-PCR）仪器为2019-nCoV无疼痛。
在癌症传染病压制该里面心的意象深入研究专家，一州和区域内医疗卫生高级官员，紧急医疗服务以及妇产科领导和保安医务人员的配合下，症状被送给往新泽西邻近地区医疗该里面心的湿气分开病房同步进行医学判读，并跟随癌症传染病压制该里面心的医护医务人员有关带入，飞沫和地面部队防护措施的建议，并带有工作服。
复发时症状调查报告结果年中肿胀，有2天的恶心和恶心日本史。他调查报告结果问道他并并未吞咽急促或头晕。生命病因在正常数限于。体格检验发掘成症状牙龈低温。其余的检验一般而言不值得注意。
复发后，症状放弃了赞同临床，包含2升生理盐水和恩丹以减轻恶心。
上图2-根据癌症日和就医日（2020年1年初16日至2020年1年初30日）的疼痛和次于心率
在就医的第2至5天（卧床的第6至9天），症状的生命病因基本保持稳定，除了经常成现经年累月发作并伴有心动过速（上图2）。症状暂时调查报告结果非生产性肿胀，并经常成现疲倦。
在就医第二天的下午，症状阴部通畅，腹部不适。里面午有第二次洗手稀少的华盛顿邮报。得来该老鼠的仪器主要用途rRT-PCR测试者，以及其他吞咽道头颅骨（楔咽和沟咽）和抗体。老鼠和两个吞咽道头颅骨后来原则上通过rRT-PCR仪器为2019-nCoV无疼痛，而抗体仍为比如问道。
其间的临床在不小层面上是近来的。为了同步进行疼痛管控，症状并不需要根据并不需要放弃利尿临床，该临床包含每4同一时间650 mg本品和每6同一时间600 mg布洛芬。在就医的前六天，他还因年中肿胀而服用了600毫克愈创醚盟约6升生理盐水。
请注意1-医学深入研究所结果
症状分开单元的性质本来数受限制即刻医疗点深入研究所测试者；从妇产科第3天开始可以同步进行全血细胞计数和抗体化学深入研究。
在妇产科第3天和第5天（癌症第7天和第9天）的深入研究所结果反映成白细胞缩减症，轻度血小板缩减症和肌酸激酶高度增大（请注意1）。此以外，败血症指标也有所变化：碱性丝硫酸酸（每升68 U），丙硫酸酸硫酸基转移酶（每升105 U），天冬硫酸酸硫酸基转移酶（每升77 U）和尿素脱氢酶（每升465 U）的高度分别为：在就医的第5天所有增大。鉴于症状连续不断发作，在第4天获血液培养成来；迄今为止，这些都并并未增长。
上图3-2020年1年初22日（脸部第7天，妇产科第3天）的后后背和末端胸片
上图4-2020年1年初24日（脸部第5天，妇产科第9天）的后后背X线片
据华盛顿邮报，在妇产科第3天（卧床第7天）拍片的脸部X光片并未揭示浸润或异常都还（上图3）。
但是，从妇产科第5天里面午（卧床第9天）里面午同步进行的第二次脸部X光片检验揭示，左肺下叶有结核病（上图4）。
这些外科发掘成与从妇产科第5天里面午开始的吞咽状态变化亦然，曾经症状在吞咽以外面湿气时通过脉搏腹水含水定量的腹水含水差值降至90％。
在第6天，症状开始放弃必需碳气，该碳气由楔导管以每分钟2升的更快输送到给。考虑到医学请注意现的变化和对妇产科获性结核病的关注，开始一般来说MRSA（1750 mg负荷mg，然后每8同一时间麻醉1 g）和红霉素锦标甲苯（每8同一时间麻醉）临床。
上图5-前后脸部X光片，2020年1年初26日（癌症第十天，妇产科第六天）
在妇产科第6天（卧床第10天），第四次脸部X射线照片揭示两个肺里面都有基底条状混浊，这一发掘成与非值得注意结核病相符（上图5），并且在听诊时在两个肺里面都经常成现了罗音。鉴于放射临床外科发掘成，要求给以碳气必需，症状年中发作，多个指甲年中无疼痛的2019-nCoV RNA无疼痛，以及发请注意了与放射临床性结核病发展完全一致的不堪重负结核病在该症状里面，医学心理医生充满活力同情心地一般来说了学术机构抗HIV临床。
麻醉瑞德昔韦（一种刚刚开发的新型硫酸基酸类似物前药）在第7天里面午开始，但并未判读到与透析有关的不良事件。在对甲碳西林耐药的紫色葡萄球菌同步进行了连续的降钙素原高度和楔PCR仪器后，在第7天里面午停止使用MRSA，并在第二天停止使用红霉素锦标甲苯。
在妇产科第8天（卧床第12天），症状的医学情况得到提高。停止必需碳气，他在吞咽以外面湿气时的碳含水差值提高到94％至96％。更进一步的双侧下叶罗音不必发挥作用。他的食欲得到提高，除了经年累月干咳和楔漏以外，他并并未疼痛。
截至2020年1年初30日，症状仍就医。他有经年累月，除肿胀以外，所有疼痛原则上已减轻，肿胀的层面刚刚减轻。
分析方法
头颅骨热带植物
根据CDC最新获主要用途2019-nCoV病因测试者的医学头颅骨。用塑胶拭子得来了12个楔咽和沟咽拭子头颅骨。
将每个拭子插入包含2至3 mlHIV转运电磁辐射的原则上无菌胸腔。将血集在抗体分离胸腔，然后根据CDC最新同步进行离心。血液和老鼠头颅骨分别得来在无菌头颅骨盖子里面。仪器在2°C至8°C之间备份，直到准备好运送给至CDC。
在癌症的第7、11和12天得来了重复同步进行的2019-nCoV测试者的头颅骨，包含楔咽和沟咽拭子，抗体以及血液和老鼠仪器。
2019-NCOV的病因测试者
一般来说从释成新闻释成的HIV脱碳核糖小分子发展而来的rRT-PCR分析法测试者了医学头颅骨。与更进一步针对重症急性吞咽肉瘤冠状HIV（SARS-CoV）和东欧吞咽肉瘤冠状HIV（MERS-CoV）的病因分析方法相似，它有着三个核衣壳性状索科利夫卡和一个无疼痛对照索科利夫卡。该定量的所述为RRT-PCR扬声器引物和间隙和脱碳核糖小分子信息里面一般来说的CDC深入研究所信息该网站2019-nCoV上。
请注意现型分子生物学
2020年1年初7日，里面国人深入研究医务人员通过宾夕法尼亚一州国立医疗卫生深入研究生院GenBank数据库库和全球共享所有霍乱数据库倡议（GISAID）数据库库共享了2019-nCoV的非常简单性状脱碳核糖小分子；随后释成了有关分开2019-nCoV的调查报告结果。
从rRT-PCR无疼痛头颅骨（沟咽和楔咽）里面浓缩小分子，并在Sanger和下一代分子生物学平台（Illumina和MinIon）上主要用途全性状组分子生物学。一般来说5.4.6英文版的Sequencher软件包（Sanger）已完成了脱碳核糖小分子零件。minimap软件包，英文版本2.17（MinIon）；和freebayes软件包1.3.1英文版（MiSeq）。将非常简单性状组与一般来说的2019-nCoV概要脱碳核糖小分子（GenBank登录号NC_045512.2）同步进行比较。
结果
2019-NCOV的头颅骨测试者
请注意2-2019年新型冠状HIV（2019-nCoV）的系统对逆转录酶-PCR-链反应测试者结果
该症状在卧床第4有道获的初始吞咽道仪器（楔咽拭子和沟咽拭子）在2019-nCoV排列成无疼痛（请注意2）。
尽管症状本来请注意现为轻度疼痛，但在癌症第4天的高于循环阈差值（Ct）差值（楔咽头颅骨里面为18至20，沟咽头颅骨里面为21至22）证明这些头颅骨里面HIV高度极高。
在癌症第7天获的两个上吞咽道头颅骨在2019-nCoV仍保持无疼痛，包含楔咽拭子头颅骨里面年中高高度（Ct差值23至24）。在癌症第7天获的老鼠在2019-nCoV里面也排列成无疼痛（Ct差值为36至38）。两种热带植物迟于的抗体仪器在2019-nCoV原则上为比如问道。
在癌症第11天和第12天获的楔咽和沟咽头颅骨揭示成HIV高度急剧下降的趋势。
沟咽头颅骨在卧床第12天的2019-nCoV测试者排列成比如问道。在这些迟于获的抗体的rRT-PCR结果仍并未定。
请注意现型分子生物学
沟咽和楔咽头颅骨的非常简单性状组脱碳核糖小分子彼此相异，并且与其他一般来说的2019-nCoV脱碳核糖小分子数数相异。
该症状的HIV与2019-nCoV概要脱碳核糖小分子（NC_045512.2）在开放学习者凸8两处数有3个硫酸基酸和1个有所不同。该脱碳核糖小分子可通过GenBank获（登录号MN985325）。
网上
我们关于宾夕法尼亚一州月所2019-nCoV胃癌病症的调查报告结果问道明了这一新兴癌症的几个方面由此可知并未完全认识到，包含散播动态和医学癌症的全部区域。
我们的病症症状曾去过里面国人成都，但调查报告结果问道他在成都期间并并未去过海鱼批发市场或医疗机构，也并并未病倒的带入。尽管他的2019-nCoV染病的来源由此可知不正确，但已释成新闻了人对人散播的证据。
到2020年1年初30日，由此可知并未发掘成与此病症之以外的2019-nCoV全身性病症，但仍在的关系情报搜集下。
在癌症的第4天和第7天从上吞咽道头颅骨里面仪器到有着高于Ct差值的2019-nCoV RNA，证明HIV负重高且有着散播实用价值。
或多或少的是，我们还在症状卧床第7天得来的老鼠仪器里面仪器到了2019-nCoV RNA。尽管我们病症症状的抗体头颅骨连续不断经常成现2019-nCoV比如问道，但在里面国人重症症状的血液里面仍仪器到HIVRNA。然而，肺以外仪器HIVRNA并不一定这样一来发挥作用传染性HIV，以以外由此可知不正确在吞咽道以外部仪器HIVRNA的医学意义。
以以外，我们对2019-nCoV染病的医学区域的认识到非常局限。在里面国人，已经华盛顿邮报了诸如不堪重负的结核病，吞咽衰竭，急性吞咽困窘肉瘤（ARDS）和心脏破损等并发症，包含致命的不堪重负后果。然而，重要的是要请注意，这些病症是根据其结核病病因断定的，因此也许但会使调查报告结果偏向来得不堪重负的结果。
我们的病症症状本来请注意现为轻度肿胀和高于度经年累月发作，在卧床的第4天并并未脸部X光检验的结核病都还，而在卧床第9天发展为结核病之前，这些非免疫病因和疼痛在后期在医学上，2019-nCoV染病的医学每一次也许与许多其他少用传染病并并未值得注意区别于，尤其是在冬季吞咽道HIV季节。
另以外，本病症症状在癌症的第9天发展为结核病的时机与近期吞咽困难的头痛（发作后里面位数为8天）完全一致。尽管根据症状的医学情况急转直下要求是否给以remdesivir慈悲的一般来说，但仍并不需要同步进行研究性试验以断定remdesivir和任何其他深入研究抗生素临床2019-nCoV染病的安全性和有效性。
我们调查报告结果了宾夕法尼亚一州月所调查报告结果的2019-nCoV染病症状的医学形态。
该病症的关键方面包含症状在学习者有关愈演愈烈的公共医疗卫生警告后要求帮助医疗；由当地医疗服务相关联认定症状不太也许到成都的之旅历日本史，随后在当地，一州和联邦公共医疗卫生高级官员之间同步进行协调；并断定也许的2019-nCoV染病，从而可以促使分开症状并随后对2019-nCoV同步进行深入研究所认定，并受限制症状复发进一步指标和经营管理。
该病症调查报告结果特别强调了医学心理医生对于任何经常成现急性癌症疼痛的就诊症状，要阐释成不太也许的之旅经历或带入病日本史的来得为重要，为了确保安全适当辨识和及时分开也许面临2019-nCoV染病风险的症状，并帮助缩减进一步的散播。
终于，本调查报告结果特别强调并不需要断定与2019-nCoV染病之以外的医学癌症，发作分子结构和HIV脱落年中时间的
全部区域和自然历日本史，以为医学经营管理和公共医疗卫生协调备有依据。
以下为英文英文版
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Summary
An outbreak of novel coronirus (2019-nCoV) that began in Wuhan, China, has spread rapidly, with cases now confirmed in multiple countries. We report the first case of 2019-nCoV infection confirmed in the United States and describe the identification, diagnosis, clinical course, and management of the case, including the patient’s initial mild symptoms at presentation with progression to pneumonia on day 9 of illness. This case highlights the importance of close coordination between clinicians and public health authorities at the local, state, and federal levels, as well as the need for rapid dissemination of clinical information related to the care of patients with this emerging infection.
On December 31, 2019, China reported a cluster of cases of pneumonia in people associated with the Huanan Seafood Wholesale Market in Wuhan, Hubei Province.
On January 7, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronirus, 2019-nCoV.
Although cases were originally reported to be associated with exposure to the seafood market in Wuhan, current epidemiologic data indicate that person-to-person transmission of 2019-nCoV is occurring.
As of January 30, 2020, a total of 9976 cases had been reported in at least 21 countries,including the first confirmed case of 2019-nCoV infection in the United States, reported on January 20, 2020.
Investigations are under way worldwide to better understand transmission dynamics and the spectrum of clinical illness.
This report describes the epidemiologic and clinical features of the first case of 2019-nCoV infection confirmed in the United States.
Case Report
On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever.
On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after treling to visit family in Wuhan, China.
The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronirus outbreak in China and, because of his symptoms and recent trel, decided to see a health care provider.
Figure 1.Posteroanterior and Lateral Chest Radiographs, January 19, 2020 (Illness Day 4).
Apart from a history of hypertriglyceridemia, the patient was an otherwise healthy nonsmoker. The physical examination revealed a body temperature of 37.2°C, blood pressure of 134/87 mm Hg, pulse of 110 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 96% while the patient was breathing ambient air. Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Figure 1).
A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. A nasopharyngeal swab specimen was obtained and sent for detection of viral respiratory pathogens by NAAT; this was reported back within 48 hours as negative for all pathogens tested, including influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43).
Given the patient’s trel history, the local and state health departments were immediately notified. Together with the urgent care clinician, the Washington Department of Health notified the CDC Emergency Operations Center.
Although the patient reported that he had not spent time at the Huanan seafood market and reported no known contact with ill persons during his trel to China, CDC staff concurred with the need to test the patient for 2019-nCoV on the basis of current CDC “persons under investigation” case definitions.
Specimens were collected in accordance with CDC guidance and included serum and nasopharyngeal and oropharyngeal swab specimens. After specimen collection, the patient was discharged to home isolation with active monitoring by the local health department.
On January 20, 2020, the CDC confirmed that the patient’s nasopharyngeal and oropharyngeal swabs tested positive for 2019-nCoV by real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) assay.
In coordination with CDC subject-matter experts, state and local health officials, emergency medical services, and hospital leadership and staff, the patient was admitted to an airborne-isolation unit at Providence Regional Medical Center for clinical observation, with health care workers following CDC recommendations for contact, droplet, and airborne precautions with eye protection.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to he dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.
Figure 2.Symptoms and Maximum Body Temperatures According to Day of Illness and Day of Hospitalization, January 16 to January 30, 2020.
On days 2 through 5 of hospitalization (days 6 through 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fevers accompanied by periods of tachycardia (Figure 2).
The patient continued to report a nonproductive cough and appeared fatigued. On the afternoon of hospital day 2, the patient passed a loose bowel movement and reported abdominal discomfort. A second episode of loose stool was reported overnight; a sample of this stool was collected for rRT-PCR testing, along with additional respiratory specimens (nasopharyngeal and oropharyngeal) and serum.
The stool and both respiratory specimens later tested positive by rRT-PCR for 2019-nCoV, whereas the serum remained negative.
Treatment during this time was largely supportive. For symptom management, the patient received, as needed, antipyretic therapy consisting of 650 mg of acetaminophen every 4 hours and 600 mg of ibuprofen every 6 hours. He also received 600 mg of guaifenesin for his continued cough and approximately 6 liters of normal saline over the first 6 days of hospitalization.
Table 1.Clinical Laboratory Results.
The nature of the patient isolation unit permitted only point-of-care laboratory testing initially; complete blood counts and serum chemical studies were ailable starting on hospital day 3.
Laboratory results on hospital days 3 and 5 (illness days 7 and 9) reflected leukopenia, mild thrombocytopenia, and elevated levels of creatine kinase (Table 1).
In addition, there were alterations in hepatic function measures: levels of alkaline phosphatase (68 U per liter), alanine aminotransferase (105 U per liter), aspartate aminotransferase (77 U per liter), and lactate dehydrogenase (465 U per liter) were all elevated on day 5 of hospitalization.
Given the patient’s recurrent fevers, blood cultures were obtained on day 4; these he shown no growth to date.
Figure 3.Posteroanterior and Lateral Chest Radiographs, January 22, 2020 (Illness Day 7, Hospital Day 3).
Figure 4.Posteroanterior Chest Radiograph, January 24, 2020 (Illness Day 9, Hospital Day 5).
A chest radiograph taken on hospital day 3 (illness day 7) was reported as showing no evidence of infiltrates or abnormalities (Figure 3).
However, a second chest radiograph from the night of hospital day 5 (illness day 9) showed evidence of pneumonia in the lower lobe of the left lung (Figure 4).
These radiographic findings coincided with a change in respiratory status starting on the evening of hospital day 5, when the patient’s oxygen saturation values as measured by pulse oximetry dropped to as low as 90% while he was breathing ambient air.
On day 6, the patient was started on supplemental oxygen, delivered by nasal cannula at 2 liters per minute.
Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment with vancomycin (a 1750-mg loading dose followed by 1 g administered intrenously every 8 hours) and cefepime (administered intrenously every 8 hours) was initiated.
Figure 5.Anteroposterior and Lateral Chest Radiographs, January 26, 2020 (Illness Day 10, Hospital Day 6).
On hospital day 6 (illness day 10), a fourth chest radiograph showed basilar streaky opacities in both lungs, a finding consistent with atypical pneumonia (Figure 5), and rales were noted in both lungs on auscultation.
Given the radiographic findings, the decision to administer oxygen supplementation, the patient’s ongoing fevers, the persistent positive 2019-nCoV RNA at multiple sites, and published reports of the development of severe pneumonia at a period consistent with the development of radiographic pneumonia in this patient, clinicians pursued compassionate use of an investigational antiviral therapy.
Treatment with intrenous remdesivir (a novel nucleotide ogue prodrug in development) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion.
Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.
On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air.
The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea.
As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms he resolved with the exception of his cough, which is decreasing in severity.
Methods
SPECIMEN COLLECTIONClinical specimens for 2019-nCoV diagnostic testing were obtained in accordance with CDC guidelines. Nasopharyngeal and oropharyngeal swab specimens were collected with synthetic fiber swabs; each swab was inserted into a separate sterile tube containing 2 to 3 ml of viral transport medium. Serum was collected in a serum separator tube and then centrifuged in accordance with CDC guidelines. The urine and stool specimens were each collected in sterile specimen containers. Specimens were stored between 2°C and 8°C until ready for shipment to the CDC. Specimens for repeat 2019-nCoV testing were collected on illness days 7, 11, and 12 and included nasopharyngeal and oropharyngeal swabs, serum, and urine and stool samples.
DIAGNOSTIC TESTING FOR 2019-NCOV
Clinical specimens were tested with an rRT-PCR assay that was developed from the publicly released virus sequence. Similar to previous diagnostic assays for severe acute respiratory syndrome coronirus (SARS-CoV) and Middle East respiratory syndrome coronirus (MERS-CoV), it has three nucleocapsid gene targets and a positive control target.
A description of this assay and sequence information for the rRT-PCR panel primers and probes are ailable on the CDC Laboratory Information website for 2019-nCoV.
GENETIC SEQUENCING
On January 7, 2020, Chinese researchers shared the full genetic sequence of 2019-nCoV through the National Institutes of Health GenBank database and the Global Initiative on Sharing All Influenza Data (GISAID) database; a report about the isolation of 2019-nCoV was later published.
Nucleic acid was extracted from rRT-PCR–positive specimens (oropharyngeal and nasopharyngeal) and used for whole-genome sequencing on both Sanger and next-generation sequencing platforms (Illumina and MinIon).
Sequence assembly was completed with the use of Sequencher software, version 5.4.6 (Sanger); minimap software, version 2.17 (MinIon); and freebayes software, version 1.3.1 (MiSeq). Complete genomes were compared with the ailable 2019-nCoV reference sequence (GenBank accession number NC_045512.2).
Results
SPECIMEN TESTING FOR 2019-NCOV
Table 2.Results of Real-Time Reverse-Transcriptase–Polymerase-Chain-Reaction Testing for the 2019 Novel Coronirus (2019-nCoV).
The initial respiratory specimens (nasopharyngeal and oropharyngeal swabs) obtained from this patient on day 4 of his illness were positive for 2019-nCoV (Table 2).
The low cycle threshold (Ct) values (18 to 20 in nasopharyngeal specimens and 21 to 22 in oropharyngeal specimens) on illness day 4 suggest high levels of virus in these specimens, despite the patient’s initial mild symptom presentation.
Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24). Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).
Serum specimens for both collection dates were negative for 2019-nCoV. Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus. The oropharyngeal specimen tested negative for 2019-nCoV on illness day 12. The rRT-PCR results for serum obtained on these dates are still pending.
GENETIC SEQUENCING
The full genome sequences from oropharyngeal and nasopharyngeal specimens were identical to one another and were nearly identical to other ailable 2019-nCoV sequences.
There were only 3 nucleotides and 1 amino acid that differed at open reading frame 8 between this patient’s virus and the 2019-nCoV reference sequence (NC_045512.2). The sequence is ailable through GenBank (accession number MN985325).
DISCUSSION
Our report of the first confirmed case of 2019-nCoV in the United States illustrates several aspects of this emerging outbreak that are not yet fully understood, including transmission dynamics and the full spectrum of clinical illness.
Our case patient had treled to Wuhan, China, but reported that he had not visited the wholesale seafood market or health care facilities or had any sick contacts during his stay in Wuhan. Although the source of his 2019-nCoV infection is unknown, evidence of person-to-person transmission has been published.
Through January 30, 2020, no secondary cases of 2019-nCoV related to this case he been identified, but monitoring of close contacts continues.
Detection of 2019-nCoV RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness is suggestive of high viral loads and potential for transmissibility.
It is notable that we also detected 2019-nCoV RNA in a stool specimen collected on day 7 of the patient’s illness. Although serum specimens from our case patient were repeatedly negative for 2019-nCoV, viral RNA has been detected in blood in severely ill patients in China.
However, extrapulmonary detection of viral RNA does not necessarily mean that infectious virus is present, and the clinical significance of the detection of viral RNA outside the respiratory tract is unknown at this time.
Currently, our understanding of the clinical spectrum of 2019-nCoV infection is very limited. Complications such as severe pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), and cardiac injury, including fatal outcomes, he been reported in China.
However, it is important to note that these cases were identified on the basis of their pneumonia diagnosis and thus may bias reporting toward more severe outcomes.
Our case patient initially presented with mild cough and low-grade intermittent fevers, without evidence of pneumonia on chest radiography on day 4 of his illness, before hing progression to pneumonia by illness day 9.
These nonspecific signs and symptoms of mild illness early in the clinical course of 2019-nCoV infection may be indistinguishable clinically from many other common infectious diseases, particularly during the winter respiratory virus season. In addition, the timing of our case patient’s progression to pneumonia on day 9 of illness is consistent with later onset of dyspnea (at a median of 8 days from onset) reported in a recent publication.
Although a decision to administer remdesivir for compassionate use was based on the case patient’s worsening clinical status, randomized controlled trials are needed to determine the safety and efficacy of remdesivir and any other investigational agents for treatment of patients with 2019-nCoV infection.
We report the clinical features of the first reported patient with 2019-nCoV infection in the United States.
Key aspects of this case included the decision made by the patient to seek medical attention after reading public health warnings about the outbreak; recognition of the patient’s recent trel history to Wuhan by local providers, with subsequent coordination among local, state, and federal public health officials; and identification of possible 2019-nCoV infection, which allowed for prompt isolation of the patient and subsequent laboratory confirmation of 2019-nCoV, as well as for admission of the patient for further evaluation and management.
This case report highlights the importance of clinicians eliciting a recent history of trel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission.
Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
This article was published on January 31, 2020, at NEJM.org.
We thank the patient; the nurses and clinical staff who are providing care for the patient; staff at the local and state health departments; staff at the Washington State Department of Health Public Health Laboratories and at the Centers for Disease Control and Prevention (CDC) Division of Viral Disease Laboratory; CDC staff at the Emergency Operations Center; and members of the 2019-nCoV response teams at the local, state, and national levels.
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